ObjectivesObjectives

Have a better understanding of how physical and mental factors affect symptomatology

Be able to use this understanding in the treatment of patients suffering from nausea/vomiting and dyspnea

Incorporate skills and knowledge gained into your practice and teaching

 

By the end of this module you will

Non-Pain Symptom Non-Pain Symptom ManagementManagement

James Hallenbeck, MDAssistant Professor of Medicine,

Stanford School of MedicineDirector, Palliative Care Services, VA Palo Alto

HCS

Definition of a SymptomDefinition of a Symptom“A physical or mental phenomenon, circumstance or change of condition arising from accompanying a disorder and constituting evidence for it… specifically a subjective indicator perceptible to the patient and as opposed to an objective one (compare with sign).”

The New Shorter Oxford English Dictionary, cited by The Oxford Textbook of Palliative Medicine

Symptoms as clues, not experiences, not suffering

From the Patient’s From the Patient’s Perspective- a Symptom Is Perspective- a Symptom Is

What Is BothersomeWhat Is Bothersome

Disease As a Clue for the Disease As a Clue for the SymptomSymptom

Disease process Symptom

Questions to ask…

How does the disease give rise to the symptom through local, central effects?

What are emotional, cognitive and spiritual components of the patient’s illness?

What Symptoms?What Symptoms?Constipation Diarrhea Peripheral Edema Nausea, vomiting Pruritus/itching Dyspnea Anxiety Anorexia Sleep disorders Cough Akathisia Dysphagia Anhedonia Death rattle/secretions Drooling Urinary Incontinence Rectal Incontinence Hiccups Flatulence Muscle spasms Confusion Memory Loss Visual problems Hearing loss Dysgeusia Colic Sexual dysfunction Polyuria Polydipsia Dizziness Dyspepsia Xerostomia Dry skin Dysarthria Dysphoria Dysuria Failure to thrive Fatigue Fear Fever Crying Hallucinations Halitosis Impotence Irritability Taste alterations Odor Mucositis Panic attacks Photosensitivity Restlessness Stomatitis Urinary frequency

N=53, Oxford Textbook of Palliative Medicine: Index, 1998.

So WHY do we have this disgusting problem?

Consider our Hungry Consider our Hungry Ancestors…Ancestors…

What protects this guy from eating something poisonous?

A Final Pathway for Nausea

CTZ CNS

VOMITCENTER

VestibularApparatus GI Tract

(Dopamine, Serotonin) ???

(Acetylcholine, Histamine) (Acetylcholine, Histamine, Serotonin,Substance P & mechanoreceptors)

(Intrinsic: Substance P, Achetylcholine, Histamine)

Pearl for the Day…Pearl for the Day…

Receptor Affinity Common Receptor Affinity Common AntiemeticsAntiemetics

The lower the number,the stronger this agent is

at blocking this receptor

Drug Dopamine 2 Musc. Chol. Histamine

Scopolamine >10,000 .08 >10,000

Promethazine 240 21 2.9

Prochlorperazine 15 2100 100

Chlorpromazine 25 130 28

Metoclopramide 270 >10,000 1,000

Haloperidol 4.2 >10,000 1,600

Adapted from Perourka, Snyder

Causes of Nausea and Causes of Nausea and VomitingVomiting

Vestibular

Obstruction (Opioids)

Mind (Dysmotility)

Infection (irritation)

Toxins (taste and other senses)

VVVestibular ApparatusVestibular Apparatus

Complaint of nausea with head movement

Mediated by acetylcholine and histamine receptors

DOC(s):– Promethazine (supp)– Scopolomine (patch, injection)– Cyclizine (oral, injection)

Most anticholinergic, antihistminic drugs will help!

OOObstructionObstruction

Most common cause: constipation May be caused by external or internal obstruction

– In advanced malignant bowel obstruction external compression most common

May be mediated through both mechano and chemoreceptors

Doc(s) – True bowel obstruction

Controversy as to best drugs– Constipation- anti-constipation meds

MMMindMind

Mediates emotional, cognitive aspects of nausea- anxiety, memory, meaning

Can be very powerful Manipulating taste and other senses often helpful Doc(s):

– Lorazapam (poor solo agent)– Appetite stimulants

Megestrol, steroids, Cannibinoids

MMDysMotilityDysMotility

Multiple causes– Opioids– Anticholinergic drugs– Stomach/bowel compression, infiltration

Upper intestinal dysmotility-very common, under appreciated

Doc(s): Prokinetics:– Metoclopramide (upper only)– Cisapride (upper and lower gut)– Senna (lower only)

IIInfection/IrritationInfection/Irritation

Mediated through chemoreceptors- acetylcholine, histamine, serotonin

Gut and adjacent organ inflammation can trigger

DOC(s): Anticholinergic/antihistaminic agents, such as promethazine

TTToxinsToxins

Most important- drugs we give Various mechanisms of inducing nausea

– Local irritant NSAIDs

– Changing blood levels (via CTZ) opioids, ? SSRIs

– Toxic blood levels digoxin

Doc(s): depends on mechanism of action

Opioid Related NauseaOpioid Related Nausea

Gut effect: Dysmotility of upper and lower gut– Doc(s): prokinetics

Effect on CTZ– Mediated through D2 receptor– Related to changing blood levels– Improves with steady state blood level– Doc(s): Haloperidol (po, inj.), Prochlorperizine (supp,

po)

Via two mechanisms:

No good evidence, rationale for using promethazine

5HT3 5HT3 AntagonistsAntagonists

Useful for certain forms of chemotherapy related nausea

May have other special uses:– In CTZ related nausea, where dopamine

blockade contraindicated– ? Other refractory CTZ related causes– ? In certain GI cases

Very expensive currently

DyspneaDyspnea

Common- 70% of dying patients in last six weeks of life

Traditional care for dyspnea largely palliative, as not curative– Focuses on lung physiology– Less attention to central processes

Pathophysiology of dyspnea poorly understood

Treating DyspneaTreating Dyspnea

Local– Low-dose opioids– Fan, cool breeze

Central– Low-dose opioids

Benzodiazepines for anxietyAddress emotional, cognitive, spiritual

factors

In addition to what you already know…

SUMMARYSUMMARY

Symptoms matter in their own right as expressions of patient suffering

Symptoms have their own “pathophysiology,”

As is true for treatment of disease, treatment of symptoms is tailored to this underlying physiology